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5 Risk factors in the development of pressure ulcers
- 1. Mobility - being confined to a bed or chair without changing areas of pressure.
- 2. Mobility - patient cannont independently change position
- 3. Moisture - caused by incontince, diaphoresis or improper drying
- 4. Poor nutrition
- 5. Lowered mental awareness
Suspected deep tissue injury
Localized intact skin that is maroon or purple or a blood-filled blister resulting from damage to underlying soft tissue from pressure or shear. The area may be painful, firm, mushy, boggy, warmer, or cooler when compared ot adjacent tissue.
Stage 1 Pressure Ulcer
Area of red, deep pink, or mottled skin that does not blanch with fingetip pressure. In people with darker skin, discoloration of the skin, warmth, edema, or induration may be signs of a stage 1
Stage 2 Pressure Ulcer
Partial-thickness skin loss involving epidermis and/or dermis. It may look like and abrasion, blister, or shallow crater. The area surrounding the damaged skin may feel warmer.
Stage 3 Pressure Ulcer
Full-thickness skin loss that looks like a deep crater and may extend to the fascia. Subcutaneous tissue is damaged or necrotic. Bacterial infection of the ulcer is common and causes drainage from the ulcer. There may be damage to the surrounding tissue.
Stage 4 Pressue Ulcer
Full-thickness skin loss with extensive tissue necrosis or damge to muscle, bone, or supporting structures; sinsu tracts may be present. Infection is usually widespread. The ulcer may appear dry and black with a buildup of tough necrotic tissue (eschar) or it can appear wet and oozing.
Unstageable Pressure Ulcer
Loss of full thickness of tissue. The base of the ulcer is covered by eschar in the wound be, or the base of the ulcer contain slough (yellow, tan, gray, gree, or brown).
When staging an ulcer be aware of...
- Stage 1 ulcers may be superficial or deep
- Stage 1 ulcers are hard to asses on people with darker skin
- Eschar must be removed to stage the ulcer
- It may be difficult to assess pressure ulcers in patients that wear orthopedic devices or support stockings.
Initial care of a pressure ulcer consists of...
debridement, wound cleansing, an the application of dressings.
What are the 4 basic purposes of bathing?
- Cleanse the skin
- Promote comfort
- Stimulate circulation to all areas of the body
- Remove waste products secreted through the skin
Key points when bathing a patient.
- maintain safety
- provide privacy
- prevent chills
- encourage independence
Which conditions place a person most at risk for pressure ulcer?
- Loss of mobility
- Poor nutrition
- Lowered mental awareness
- Confinement to a bed or chair
Initial care of a pressure ulcer involves...
- Wound cleansing
- Application of dressings
What is a partial bath?
- Only certain parts of the body are bathed, such as the face, hands, axillae, back and perineal area
- Complete bath done partially by the patient
Which therapeutic baths are available?
- Whirlpool - cleanse, stimulate peripheral circulation and provide comfort
- Starch/oatmeal - soothes dermatitits
- Sitz - promotes healing and relieves pain in the perineal area (used after birth and vaginal or rectal surgery)
- Body Soak - cleanse open wounds or apply medication
How often should oral care be provided?
- 4 times per day for the concious (ideally)
- every 8 hours for the unconscious
- every 4 hours for unconscious mouth breathers; moist swabbing ever 2 hrs
- usually done with the bath
- toenails of diabetics and patients with circulatory disease of the lower extremities need a physicians order
- Observe the nail beds for signs of circulation issues
- Use alcohol, water or astringent to untangle hair
- Never cut hair without patient consent
Determine if a safety razor is acceptable based on patient health status